Improving LGBTQ+ Health: Robert Coulter

Robert: While there is some work being done, it's not being rigorously evaluated, which also means that, then we can't scale it up and make it more widespread because we just don't know the scientific validity of these interventions. And so that's really where my work is headed. Both designing interventions, as well as rigorously testing them so we can actually reduce these disparities that we've known about for nearly 30 years already.

Mike: From CTSI, this is the Products of Pittsburgh. A show about the people in Pittsburgh – innovators, scientists, community leaders – and the remarkable stories behind how they came to be and the work they’ve produced. I’m Mike Flock. On the show today, we catch up with Dr. Robert Coulter, Assistant Professor of Behavioral and Community Health Sciences at the University of Pittsburgh    

Mike: Robert is on a mission, to eliminate substance use and violence inequities for sexual and gender minority youth. And he is striving to do so through research, examining the complex social mechanisms that produce health inequities and then designing, implementing, and evaluating interventions aimed at reducing violence and substance use inequities for sexual and gender minority youth, individuals who identify as lesbian, gay, bisexual, transgender, queer, questioning (LGBTQ)  and anyone who doesn’t identify as cisgender and heterosexual. But before becoming a professor and studying the complex dynamics of health inequities, Robert was playing music and doing math. He was born in Lewiston, New York, which is near Niagara Falls along the Canadian border, the same town where his parents were also born and raised. Robert’s father is a retired building inspector and police officer, and his mother is a teacher. He has had a few other influences as well.

Robert: I have three older sisters; my youngest sister is 12 years older than me and my oldest sister is 23 years older than me. So, I often tell people I have four mothers, three sisters and my actual mother. I am the only boy in the family. And I'm younger by many, many years. Yeah, and I'm pretty close with all my sisters. We all live all over the country. But, uh, we have good relationships with each other.

Mike: So, growing up with sisters that much older than yourself, did they have any particular influences on you and of your education and upbringing?

Robert: I do think that especially my younger sister did because when I was in first grade, my youngest sister ended up going to college. And so, I got to see her go to college, get her master's degree, get her education doctorate. And so, I remember growing up laying on like our couch in the living room and asking her questions about college and graduate school and what it was like. And so, I knew from a very young age that that was what I wanted to emulate so that she definitely had a profound influence over my desire to obtain higher education.

Mike: Were there any particular areas of interest that you had in terms of a career. Let's say when you were in junior high or high school?

Robert: Yeah, so in high school I really, really loved both math and music. Those were like my two special loves and I was considering going to school for music, but I'm very glad to report that I did not go to school for music because I don't think that that would have been good for my perfectionistic side because music school can be very, very onerous, if you will. So anyways, I ended up going to school for math. I was a math major in college. I thought how great would it be to study math all the time. Little did I know.

Mike: Interesting. And so, when you say music was it more so an instrument or singing?

Robert: Yeah. So, I played the oboe from fourth grade through my first semester of college and I really loved playing the oboe. I also played the English horn, which is also a double reed instrument. I even played the bagpipes, too, during my high school years but I considered going to school for oboe and I'm also really glad I didn't in the end. But then I did try to take concert band which was the band for non-music majors at Syracuse University, my first semester. And if you know anything about orchestra or band, you'll be surprised to hear that this band had six oboes in it. That is a very high number of oboes and I decided quickly thereafter, I was like, never mind. I don't need to be in this band with six other oboes.

Mike: But math. So how did you land on math?

Robert: Well, my mother was a math major in her undergraduate career. And so I think I have a natural proclivity to math, and I don't think she really had a profound influence over my being a math major, other than I think that she passed down the math gene, if that's a thing. We are definitely both very analytically inclined and so math was one thing that my brain just really likes to do. I still do a lot of math in my job currently, much more statistics and applied math. And I also really, I find that even in my free time puzzle kinds of games that require sort of mathematical strategies, if you will, are definitely my go to games of choice when I'm trying, trying to escape for a minute.

Mike: So, going from math to public health, a bit of a transition. What made you decide to go that route?

Robert: So as an undergraduate student, as I mentioned, I thought that it was going to be really great to be a math major and when I first got to Syracuse, the first six courses of math that you take are much more applied mathematics and then as soon as you declare becoming a math major or, at least, this was the program when I was there, everything switched over to theoretical math; we were barely even using numbers at those times and while my brain was good at those things, my emotions told me I didn't very much like it. Because I couldn't see the real-world application of these mathematical theorems that I was doing. I just, there was no practical, real-world application to it. And I was really defeated by that, in many ways, I wanted to put things to good use. So, I started to look around at other majors and minors during my career at Syracuse University. And I tried chemistry. I tried philosophy. I tried a bunch of different fields and I actually stumbled upon an LGBT studies minor at Syracuse University. And that was a very interdisciplinary minor that got me introduced to sociology, to social work, to queer studies, to general women's studies, to African American studies. And that minor really got me interested in sociology and social research just generally. And I considered going on to get my PhD in sociology, however, during my time at Syracuse I had no research experience. So, I decided to try to find a job after my undergrad, that my search terms incredulous at that time to find this job were “social research.” And I ended up finding a job. I was looking in the Boston area because that's where my partner was living at the time so I wanted to move out there. And I found a job at the Education Development Center and I ended up working under a principal investigator who studied adolescent health, as well as HIV prevention, and so I ended up working in public health, she was very much a public health researcher in many ways, and I worked in public health and that's when I discovered public health. I don't even know what public health was until my boss was like, “oh you should consider going to get your master's in public health, that might be really great.” And so, I ended up taking a class or two before I actually applied and enrolled in the program at Boston University's Master of Public Health Program. So, that's how I found public health, sort of, by chance, in many ways.

Mike: And so I'm sure the math component helped, as you mentioned, in terms of the statistical components of public health and epidemiology and things of that nature, perhaps, were there other I guess learning curves that you had experienced transitioning from math to public health?

Robert: Yeah, so I knew that I did not want to be known as the mathematician or the statistician on the team, that was never my goal. I wanted to step away from math. So, I actually concentrated in behavioral and community health sciences, or I think they call it social and behavioral sciences health sciences at Boston University. So, I was much more in the behavioral realm of things. And that was a great match for me, I really enjoyed learning about the social theories of behavioral health theories, so on and so forth. I get to talk a lot about sort of the perfect blend of the applied mathematics with the applied sociology, if you will. And so, it was a perfect blend of both my interests and my skill set. As I was going through the MPH program I quickly realized that I wasn't going to have as many of the methodological knowledge because the masters of public health was much more of a practice oriented degree and I wanted to be able to read a research study and understand the method that they used and the statistical tests that they use and all those components. And so, instead of taking extra classes without getting a degree I decided, okay, it's time to go on and get my PhD and I would love to run my own studies, as well. And so that's what really drove me to start to look for PhD programs. And I ended up here at the University of Pittsburgh in the Graduate School of Public Health and the department that I'm actually now a faculty member in and the reason that I chose the University of Pittsburgh was because they had a Center for LGBT Health Research and at the time, back in 2012 when I enrolled, it was one of the few programs in the country that actually had like a centralized unit that was focused solely on LGBT health. Now while at many other universities at that time there were individuals that were working on LGBT health, there was less of a centralized sort of unit that brought everyone together on a regular basis. And so, I chose to come work here, start my doctoral studies here under the mentorship of Dr. Ron Stall.

Mike: In 2017, Robert received his PhD and became a postdoctoral scholar in the Department of Pediatrics. It was a change of scenery and focus, going from the School of Public Health to the School of Medicine; yet, in 2019, Robert would find himself back in Public Health, accepting an Assistant Professor position in the Department of Behavioral and Community Health Sciences, with a secondary appointment in Pediatrics. Although his research continues to evolve, his primary question remains the same – how might we improve the health of LGBTQ youth and young adults? And needless to say, he’s already making an impact.  

Robert: During my doctoral career, I really focused on studying the patterns of substance use, violence victimization, and mental health among LGBTQ youth and young adults, as well as what were the drivers of those disparities that we were seeing in those areas for LGBTQ youth. And so, a lot of that was much more epidemiologically focused, analyzing large survey data and trying to find correlates of disparities, and since then I really quickly realized that I would write discussion section after discussion section saying that we really needed more interventions on LGBTQ youth to improve these dramatic inequities that we're seeing for LGBTQ youth across so many preventable health outcomes. During my dissertation, actually, I started to pivot my focus much more towards intervention work. And I did that by conducting a systematic review of the literature to understand what kinds of interventions were out there, specifically for drug use, substance use, mental health, and violence victimization, and in that study, I believe we found that there were only nine interventions, many of them with weak methodological rigor. So, they weren't even necessarily very informative because they weren't conducted in the most scientifically rigorous way. And so, we're still left with very little knowledge about how we can actually improve the lives and health of LGBTQ youth. And that's really where I spent my time focusing over the last three years since I graduated from my PhD program.

Robert: I should say, I really want to make a plug there because there is a ton of LGBT interventions happening from grassroots organizations and community-based organizations. But they aren't necessarily being evaluated, so we don't know how much they're actually working and accomplishing the goals of the program. And so, while there is some work being done, it's not being rigorously evaluated, which also means that, then we can't scale it up and make it more widespread because we just don't know the scientific validity of these interventions. And so, that's really where my work is headed. Both designing interventions as well as rigorously testing them so we can actually reduce these disparities that we've known about for nearly 30 years already. One of the reasons that we might not have evaluations of interventions at this point is because so many national surveys, and even statewide surveys, didn't include measures of sexual orientation and gender identity in those large surveys so we weren't able to necessarily for many years articulate what the health disparities actually were for these populations. Now, many more surveys are incorporating measures of sexual orientation and gender identity so, we are able to see these very stark and dramatic health inequities for them. And so, now that we've achieved that level of epidemiological rigor, I really think we can take it to the next level of doing intervention science with these communities to really make impacts in these population level health disparities that we're seeing.

Mike: So, you mentioned design. What do you mean by sort of the element of design?  

Robert: Yeah, so I'm not a clinician or a provider in any sort of way. And I've always been a little jealous of clinicians and providers, not in the sense that I want to heal people of their problems or how those kind of patient provider interactions, because that's not something that I really want in my life. However, I've always been a little jealous that they've had interactions with the population of interest. So, for me during my doctoral program, I was largely doing epidemiologic survey research and I wasn't interacting with participants in any sort of meaningful way. And so, my primary mentor, Liz Miller, during my postdoc, and even now, does a lot of stakeholder engaged research. And so, I was able to, through my working with her, start to work with stakeholders and interview students, LGBTQ youth, interview school staff, a lot of my work is focused on changing school environments now. And so I'm very fortunate now that I have interactions with the community in a much more substantial way.

Robert: However, I think the point that you’re trying to get to is that I've been very fortunate to learn human-centered design techniques through the CTSI and through the LUMA Institute I learned these human-centered design techniques and they're essentially proven ways in the business world of engaging in meaningful ways with stakeholders to find solutions to problems that have plagued us for a long time. And there's a wide variety of methods that can be used and they're often very engaging with the stakeholders, or with the participants that you're working with and so I'm using a lot of those human-centered design techniques. Now, to have youth as well as adult stakeholders in the community brainstorm solutions to, for example, in one of my grants, we're developing a school staff-based intervention specifically for high schools. So how can we create a meaningful intervention for school staff as well as for LGBTQ youth and so we're getting input from both communities on what the intervention should look like, what it should include, what should its main goals be, and human centered design techniques have allowed us, especially in this new, all-virtual environment to really engage in meaningful ways with them. So, we're using an online platform called Miro that allows us to engage in sort of the whiteboard and post-it note environment that we often like to use and human-centered design in person and now we're able to facilitate a very similar kind of environment using Zoom and Miro just online and, I've really been enjoying using it with my research teams as well as with my research participants to engage in these methods.

Mike: Human-centered design is a flexible and repeatable approach to innovation that puts people, humans, at the center of the activity. Robert is a certified practitioner of human-centered design and incorporates these skills into his research, bringing together different stakeholders to participate in the process of designing complex interventions and how to best implement them. He received an award through CTSI’s Research Initiative for Special Populations or CRISP, to develop interventions to reduce adolescent relationship abuse among sexual minority youth. For this work, LGBTQ youth are actively involved in the process of coming up with different intervention ideas that can be tested in the field, which has led to key insights and important learnings along the way. 

Mike: Through these experiences and your research has there been anything thus far that’s really surprised you?

Robert: Yeah, I just had a very surprising meeting with the Youth Research Advisory Board and what they informed us of, they thought that the most important purpose of the school staff-based intervention to reduce LGBTQ health disparities and mental health and substance use was making sure that school staff know when and when not to disclose an LGBTQ student’s identity. For example, let's say someone reports an instance of bullying, it can often be over one’s perceived sexual orientation or their actual sexual orientation or gender identity or expression. And so, I imagine in many of those circumstances teachers are often outing kids and the youth that we're talking with are suggesting that that is a huge problem that needs to be addressed in schools. And I can imagine that school staff, and we haven't, because this just happened a couple days ago, we haven't spoken with school staff and gotten their input on this yet but I imagine that in many instances school staff don't know exactly when it's right or wrong to out a kid as LGBTQ youth because oftentimes they're probably thinking that it's in their best interest to out them to understand the full context of whatever's happening but there are also some major privacy issues of those kids. So, for example, many kids are out at school, but not necessarily out to their parents so if they're involved in some sort of major incident at school, it can be very problematic for a school member to call their parents and let them know what's going on and it could put these kids at harm in their home lives, which is probably why they're not out there in the first place. And so this whole aspect of disclosures, really interesting, it's not one that I would have personally said is the most important thing to address, but we're hearing from youth that it actually is a very important thing to address. And so, that's what's been really neat to be able to get these different perspectives and have kids engage with these things and in  virtual environments to be able to tell us, but what they think are the most important things

Mike: Have you experienced any challenges or barriers to implement..?

Robert: The number one barrier that we always have is just technology right? Zoom is likely to get all fuzzy or break up. We found that the adults that we work with are much more amenable to human-centered design techniques because they're so used to using computers so we can use Zoom and we can use like the internet web browser, at the same time. Whereas, many of the youth that we work with, they want to use their phone, and using Zoom and Miro which they have to download as an app on their phone becomes a little more challenging with them. So, we have to spend a lot of time before we even get to the meeting, getting them up to speed about like how they're going to use it on their phone, if they're going to use their phone, or we encourage them to use a laptop but as you know, not all kids have laptops. So, that's probably been the primary challenge of all of it. But I would say that we've gotten really, really good feedback from our participants about the activities that we do. One of our stakeholders, and I don't take this lightly, said that this was the most effective virtual meeting that they had. And it was like, yes, kudos to us because we spent a lot of time planning this meeting and making it effective and not boring and horrible because if I sat there and lectured at people about health disparities or something for 45 minutes, I imagine everyone on Zoom would end up turning their cameras off and doing something else, because it would just frankly be very boring. So, I think these human-centered design activities online allow people to engage in much more meaningful ways with the ideas that are being presented because they can read them, they can talk about them, they can move them around on this virtual whiteboard space. And so I think that it's been working out very well, but I would say definitely technology is the biggest hurdle for us, though, so I'm so thankful with where we are right now that we can do this.

Mike: Robert isn’t just conducting research. He’s mentoring students and teaching graduate courses on multi-level statistics and system theories and approaches. Health is, complex, with feedback loops and interrelated variables. If one thing changes, the whole system may change. So how would one analyze such a complex system and identify drivers of health disparities?  Robert’s natural math abilities certainly gives him leg up in trying unravel the complexity and help others dig into these challenges as well.  But when it’s time to unwind and take time for himself, he does have a few new hobbies… 

Mike: You mentioned potentially going into music and playing the oboe, for example, any other hobbies or interests outside of your work?

Robert: My pandemic hobby has been learning about plants and ordering plants and repotting plants and doing everything with plants. Someone referred to it as a plants-demic, if you will. So that's been one of my primary things these days. All indoor plants because I live in an apartment and don't have outdoor space. But that's been very fun lately to do. Yeah, and a lot of my hobbies have had to shift a little bit because my hobbies tend to be more socially oriented and since the pandemic, a lot of them have had to go away, but I'm a member of a book club. And so we're meeting on zoom on Saturday, actually, to, to discuss the book that we're doing. So that's been fun. We do dinner a few friends and I do dinner club still. And so, we're still during even during the pandemic, we would all get the same takeout together. And so that's been fun. During the pandemic, we were also using Netflix party. Have you heard of Netflix party? It’s a way to all watch, as long as you all have Netflix, you can watch Netflix at the same time. So that's been fun, too.

Mike: What does your family, whether it's your sisters or parents, think of the work that you've done and now being a faculty member at University of Pittsburgh and doing the research that you're doing?

Robert: My family is definitely very proud of all that I've done and what I stand for so that's very reassuring. My sister yesterday was just asking me if I was concerned that I was going to be burning out. I was telling her, well, you know it all ebbs and flows. Sometimes we have very strung out moments and I'm pretty good at hitting the brake pedal, but I know when I need brakes. One right now would actually be very great not like right now but like a vacation next week would be awesome. But vacations are sort of on the back burner at this moment. But yes, they're generally very proud of all that I've accomplished. And so that's very reassuring.

Mike: One question I do ask everyone that we interview is if there's one word that you could select to describe yourself, what would that one word be?

Robert: Wow, that's hard. Wow, that is really complex. What answers have you received?

Mike: It's been, it's been a spectrum.

Robert: Oh, I don't know. This is so hard. I've just been thinking of so many that come up in my mind, but none of them are like the essence of me. How does one, how does one actually summarize their essence in a single, single word?

Mike: Of the ones that were kind of in your head, are there any particular ones, knowing that there's probably obviously multiple words that you could select?

Robert: I think, in this instance, like the one thing that pops up is “scientist,” I definitely think of myself as a scientist. I like to think that I'm kind and caring and that is more important to me than getting all the research papers and getting all the grants done, I care much more about people. I am a very loyal person to my friends and to my teens and to my family. And so, I think loyalty probably or loyal is one of the most important.

Mike: Robert Coulter, PhD, MPH Assistant Professor of Behavioral and Community Health Sciences, and Pediatrics at the University of Pittsburgh.

That’s our show. Thank you for listening to the Products of Pittsburgh. Be sure to check out our website at http://www.ctsi.pitt.edu/podcast to hear more episode as well as learn about CTSI programs and services. I’m Mike Flock along with Zach Ferguson, until next time on the Products of Pittsburgh.